FORM 1 - ENVIRONMENTAL CLEARANCE WORKSHEET
A. Name of City.
B.Project name and location.
C. Brief description of proposed activity.
D. 1) Are there properties listed on, nominated to or eligible for
nomination to, the National Register of Historic Places on the
site, or in the vicinity of the proposed activity?
yes ___ no
2) If yes, does the proposed action have an effect on the properties?
yes ___ no
3) How has this determination been made?
E. Environmental Checklist:
Rate the proposed activity of the following environmental components in terms of
actual or potential impacts on the project on the environment on the project.
The rating scale is as follows:
0 = no impacts.
1 = minor impacts (i.e., those impacts which can be easily mitigated with minimal extra expenses or delay in project implementation).
2 = major adverse impacts (i.e., those impacts which cannot be mitigated or which would require extensive mitigate long delays of project implementation
N/A = not applicable to the type of activity proposed.
01. Unique geologic features on
site or in vicinity______
02. Valuable geologic resources
within 1 mile of site______
03. Slope stability/rockfall ______
04. Depth of impermeable layers ______
05. Subsidence______
06. Consolidation (geologic) ______
07. Seismic risk______
08. Foundation support______
09. Soil plasticity______
10.Frost susceptibility______
11. Liquefaction______
12. Erosion/sedimentation ______
13. Soil permeability______
14. Abandoned, active or planned
sanitary landfill______
15. Wetlands______
16. Coastal/zones/shorelines ______
17. Mine dumps/spoil areas ______
18. Hydrologic balance ______
19. Aquifer yield______
20. Drainage______
21. Flooding______
22. Water quality______
23. Ground water______
24. Surface water______
25. Unique or endangered animal species______
26.Vegetative community ______
27.Plant/animal diversity ______
28.Nutrient cycling______
29.Special climatic conditions ______
30.Forest/range fires______
31. Energy resources______
32. Air quality______
33. Education facilities:
Elementary______
Junior high/senior high ______
other (specify)______
34. Employment______
35. Commercial facilities______
36. Health care/social services ______
37. Water supply system______
38. Sanitary sewer system ______
39. Storm sewer system______
40. Solid waste disposal______
41. Police and fire protection ______
42. Parks/playgrounds/open space use______
43. Other recreation facilities ______
44. Public transportation______
45. Cultural facilities______
46. Site hazards______
47. Structural safety______
48. Safety (materials)______
49. Cultural patterns______
50. Road safety and design ______
51. Noise:
Airports (within 15 miles)______
Railroads (within 3,000 feet) ______
Major roads (within 1,000 feet)______
Other (specify)______
52.Vibration______
53. Odor______
54. Light ______
55. Temperature
56. Socio-economic character of the neighborhood______
57. Physical character of the neighborhood______
58. Crime levels______
59.Nuisances______
60.Compatibility of land uses______
61 Aesthetic compatibility______
AUTHORIZATION TO RELEASE INFORMATION
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
I/we hereby authorize the Mid Iowa Development Association (MIDAS) Council of Governments or any of its affiliates/support agencies to make all inquiries it deems necessary to verify the accuracy of the information provided herein, and to determine my/our credit worthiness for any purpose related to our credit transaction with them. I/we hereby certify that the enclosed application information including attachments/exhibits are valid and correct to the best of my/our knowledge.
I/we hereby authorize the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies to furnish relevant information to all necessary sources including various federal, state and conventional funding opportunities to obtain the best sources for the project
I we further agree that I shall indemnify and hold the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies harmless from any claim or cause of action arising because of incorrect, inaccurate or incomplete information furnished by me/us, whether the furnishing of such incorrect, inaccurate or incomplete information was accidental or intentional and in consideration of the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies' assistance, I/we waive all claims against the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies, its personnel or counselors arising from this assistance.
Signature Date
INDEMNIFICATION AGREEMENT
BORROWER(S) hereby agree to indemnify and hold harmless the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies from and against any liabilities, losses, damages, suits, judgments, counsel fees, or costs arising attributable to the release, discharge, manufacture, production, storage or disposal or the presence of hazardous toxic substances, on, or under borrower's property or property in which the borrow has an interest and based upon claims assertible by local, state, and federal governmental authority or other third parties against the Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies.
This indemnification will specifically survive, and is entirely independent of; the debtor's contractual obligation to repay the primary obligation held by Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies as amended, extended, or renewed by Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies prepayment in full of the borrower's indebtedness Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies; and release of Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliates/support agencies liens on the borrower's real or personal property by payment, foreclosure, or action including Mid Iowa Development Association (MIDAS) Council of Governments and any of its affiliate’s discretionary abandonment of lien.
Signature Date
Other items to be attached to this application:
- Business Plan (Attach as Exhibit 1)
- Cash-flow Summaries and/or Profit/Loss Statements (Attach as Exhibit 2)
- Credit Reports (for Private Developer Applications) (Attach as Exhibit 3)
- Appraisal Reports (If real property is included within the application) (Attach as Exhibit 4)
- Personal Financial Statements (If private developer application) (Attach as Exhibit 5)
- Documentation of commitment of other funds (Attach as Exhibit 6)
APPLICANT SIGNATURE
All information contained herein is TRUE and CORRECT to the best of my knowledge.
SIGNATURETITLEDATE
SIGNATURETITLEDATE
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